Approach to headache

• Evaluation focuses on determining whether a secondary headache is present and checking for symptoms that suggest a serious cause
• If no cause or serious symptoms are identified, evaluation focuses on diagnosing primary headache disorders.

On history

• First question

☆ Is this a new or old headache? Is this headache like the ones you usually have?

• Old headaches are usually primary headaches and are not dangerous- such as migraines, tension headaches, cervicogenic headache etc.
• New headaches are more likely to be due to a secondary headaches and should raise the flag regarding a dangerous etiology

At what age did the headache begin?

• Primary headaches can occur at any age but most often begin during childhood or between 20 and 50 years of age.
• Onset of headache after 50 years of age is a red flag for consideration of a secondary headache disorder such as temporal arteritis or a mass lesion.

What are the associated symptoms? The patient should be asked to describe current symptoms well as symptoms experienced before, during and after the attack

• Primary headache disorder such as cluster headache (ipsilateral lacrimation and/or nasal congestion) or migraine with aura (e.g., scotomata, photophobia, phonophobia, nausea).
• Secondary headache disorder (diplopia, dimming of vision in a single eye, stiff neck, disorientation, rash, fever, eye pain, unilateral paresthesias, unilateral weakness, balance change).

History

Onset and progression

• Patients should be asked about the time and nature headache onset (e.g., gradual, sudden, subacute).

• Headache of sudden and severe onset can be due to:

• SAH

• Vascular malformations (ruptured or unruptured)

• Acute ischemic Cerebrovascular disorder

• Posterior fossa mass lesions.

• Cluster headache

History

Severity and quality of pain

• Tension headaches: mild to moderate, compressive or squeezing pain
• Cluster headaches: severe, stabbing in nature
• Migraine headaches: moderate or severe, pulsating or throbbing

Frequency and duration of pain

• Migraine-duration of 4 hours to 3 days, periodic in occurrence; several per months to several every year
• Tension headache-duration of 30 minutes to several hours
• Cluster headache-duration of 30 minutes to 3 hours, may occur multiple times in a day for months

History

Location and radiation of pain

• Cluster headaches are strictly unilateral.

• Tension-type headaches are usually band-like and bilateral.

• Migraines generally begin unilaterally but may progress to involve the entire head.

• Pain along the distribution of the temporal artery may suggest temporal arteritis, and pain along the distribution of the trigeminal nerve may be a sign of trigeminal neuralgia

• Eye pain may suggest acute glaucoma

History

Current and past medical history (medical history) - risk factors

• Meningitis
• HIV
• CNS lymphoma
• Toxoplasmosis
• Malignancy
• Intracranial vascular disorder
• Acute viral syndrome or acute bacterial infection
• Hypertension
• Immunosuppressive disorders
• coagulopathy or taking anticoagulation

History

Medication/drug use history

Use or withdrawal form medication can cause headaches

• Prescription and over-the-counter medications (especially caffeine-containing analgesics) have implicated as triggers for drug-rebound and nonspecific headaches

History

Don’t forget to ask about trauma

Trauma or recent instrumentation

• Headache after trauma may signify post concussive disorder, although ICH should always be risk stratified.
• Migraine and cluster headaches may be triggered by head trauma.
• Headache has also been associated with common medical procedures (e.g. LP, rhinoscopy) and dental procedures (e.g., tooth extraction).

History

TRIGGERS/AGGRAVATING /RELIEVING FACTORS

• Migraine -The pain is generally made worse by physical activity
  • triggers include menstruation, loud noise, stress, heat, alcohol, stress, OCP, dietary triggers such as MSG

FAMILY HISTORY

• migraine has strong family history

PSYCHOSOCIAL HISTORY

• Substance abuse
• Occupational and personal life
• Psychologic history
• Sleep history

Physical exam

Systematic assessment

• General appearance well or ill
• Vitals signs
• Cardiovascular assessment(CVA risk)
• ENT exam
• facial palpation(sinusitis, mastioditis, GCA)
• funduscopy

exam

Full neurologic exam

• Mental status
• Level of consciousness
• Cranial nerve testing
• Motor strength testing
• Deep tendon reflexes
• Pathologic reflexes (e.g. Babinski’s sign)
• Sensation
• Cerebellar function
• Gait testing

Signs of meningeal irritation (Kernig’s and Brudzinski’s signs

Identifying ‘red flags’

“red flag” symptoms means that a headache warrants further testing including blood work and advanced imaging

• Headache beginning after the age of 50 (GCA, mass lesion)
• Sudden onset, rapidly progressive headache (SAH, ICH, mass+ICH, AVM)
• Headache that is interactable (mass, subdural, medication disuse, venous thromboses) (not getting better)
• New-onset headache in patient with risk factors for HIV infection or malignancy (brain abscess, meningitis, metastasis) anti-coagulation

’red flags’

• Headache with signs of systemic illness (e.g. fever, stiff neck, rash indicating meningitis)
• Focal neurologic signs (mass lesion, vascular malformation, stroke, collagen vascular disease evaluation)
• Papilledema (mass lesion, pseudotumor cerebri, meningitis)
• Headache subsequent to head trauma (ICH, subdural hematoma, epidural hematoma, post traumatic headache)
• Headache triggered by cough, exertion or while engaged in sexual intercourse—Mass lesion, subarachnoid hemorrhage

Investigations

only in secondary

Lab testing

• Routine use of laboratory testing in the evaluation of acute headache is not clinically useful.
• CBC when systemic or intracranial infection is suspected
• ESR/CRP if giant cell arteritis (GCA is a concern)

Neuroimaging

• Neuroimaging is not usually warranted in patients with primary headaches.
• CT scanning test of choice to identify acute insult.
  • non-Contrast
  • with Contrast → stroke
• MRI is best for brain tumors and problems in the posterior fossa, or back of the brain
• MRI should be done if patients have any of the following:---Focal neurologic deficit of subacute or uncertain onset, Age > 50-years, weight loss, cancer, HIV, diplopia or a change in established headache pattern

Investigations

Lumbar puncture(CSF analysis)

• Warranted if hemorrhage, encephalitis, idiopathic intracranial hypertension is being considered

Tonometry and fundoscopy

• Should be done if findings suggest acute narrow-angle glaucoma (eg, visual halos, nausea, corneal edema, shallow anterior chamber).